Provider Demographics
NPI:1962418277
Name:BROOKS, JEFFREY SCOTT (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 419074
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9074
Mailing Address - Country:US
Mailing Address - Phone:314-432-1903
Mailing Address - Fax:314-432-5105
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-432-1903
Practice Address - Fax:314-432-5105
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000366213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO300900842Medicaid
MOT42804Medicare UPIN
MO480022596Medicare PIN
MO300900842Medicaid
MO001012738Medicare PIN
001012739Medicare PIN